OBJECTIVE: To
estimate the prevalence of intimate partner sexual violence among men and women
of the Brazilian urban population and factors associated to it.METHODS: The data analyzed is part of the study conducted between 1998
and 2005 among urban populations in Brazil. The data was obtained by means of
a questionnaire applied to a representative sample of 5.040 individuals, men
and women 16 to 65 years of age. Descriptive analysis was undertaken with weighted
data, utilizing F design-based tests, with 5% significance.RESULTS: The global prevalence of intimate partner sexual violence was
8.6%, being predominant among women (11.8% versus 5.1%). Women consistently
reported higher rates of violence then men, except in cases involving homo/bissexual
partners. The rate verified for male homo/bisexuals was significantly greater
than that found among male heterosexuals, but this difference in rates was not
significant among women. The Black population, irrespective of sex, referred
more violence than theWhite population. The lower the income and years of formal
education, the greater the rates of violence. However, men from poorer regions
referred more violence, but this did not occur with respect to women. Diverse
situations with respect to work, use of condoms, lower age at first intercourse
and number of partners during the last five years differed significantly among
women, but not among men. For both men and women sexual violence was associated
with being separated or divorced, having had STDs, self-evaluation of being
at risk for HIV, but was not associated with testing positive for HIV.CONCLUSIONS: The high magnitude of sexual violence as well as female
surtax is confirmed. Violence as a result of gender conflicts, that pervades
social stratification and ethnic groups is reiterated. As to the Aids epidemic,
sexual violence is an important factor to be taken into consideration when discussing
the feminization of the population affected by the disease.

Sexual violence
is a worldwide problem. Although there are many different ways of delimiting
this form of violence, Krug et al18 define sexual violence as undesired
sexual acts, attempts to obtain a sexual act or advances, in which coercion
is utilized and that are practiced by any person, regardless of their relationship
to the victim and in any setting, whether or not it be the home. It includes
acts of rape, (forced penetration) within marriage or dating relationships,
or as practiced by strangers or even in the midst of armed conflicts. It also
includes sexual harassment: acts or advances, such as coercion and forms of
payment or of demanding sexual favors in return for benefits accrued within
the context of hierarchical relationships (at work or school). Sexual acts in
which penetration does not occur, that in Brazil are defined as violent assaults
against modesty, are also considered sexual violence. These acts include coercion,
exhibitionism and voyeurism, coercion in the practice of pornography, forced
prostitution, forced genital mutilation and traffic of boys, girls and women.15

Designations are
also diversified, such as sexual crimes, sexual abuse, sexual aggression and
sexual violence. The term abuse, very common in medical literature, is sometimes
considered as pertinent to those cases in which there is no penetration. Furthermore,
there is the designation sexual assault, the use of which is restricted to the
English language.

Excluding sexual
violence involving children and adolescents, this theme has not been studied
a great deal. The major difficulties are those posed by conducting populational
inquiries more frequently. As a result, studies rely on estimates with respect
to prevalence based on data collected in schools,22 organisms that
denounce violence such as police departments or services that attend victims
of violence.7,18 This holds true for the majority of Brazilian publications,
almost always undertaken in conjunction with the evaluation of the service being
considered.1,12,19

In a revision of
international studies referring to the period between 1992 and 2007 with adults
of both sexes, Krug et al,18 indicated that, on the average, approximately
20% of the female and 5% to 10% of the male population suffered sexual abuse
in childhood. As to the occurrence of sexual aggression between youth and adults,
this same publication,18 revealed that among women aged 16 or over,
the prevalence varied from 0.8% in Gaborone (Botswana), 2% in Budapest (Hungary),
2%-3% in Johannesburg (South Africa), to 8% in Rio de Janeiro (Brazil). In 2004,
a Brazilian populational survey undertaken with a representative sample of 2,502
women aged 16 years and over, revealed a 13% prevalence of reported sexual violence
at least once in their lifetimes.28

As to the male
population, international data indicate rates of sexual aggression at least
once in their lifetimes among adolescents in third world countries that vary
from 3.6% in Namibia to 20% in Peru.18 A Brazilian study undertaken
with 798 men aged 18 to 60 years old, who sought two public primary health care
services within São Paulo for assistance,ª
revealed rates of sexual violence of 6.1%. On the other hand, the occurrence
of sexual violence at least once during the lifetime among women always reveals
higher rates than those found among men. A national survey conducted in the
United States in 1998, with 8,000 men and 8,000 women over 18 years old identified
a lifetime prevalence of sexual violence of 17.6% and 3.0%, for women and men
respectively.27 Among adolescents, young women also present higher
rates of forced sexual initiation than young men: 29.1% versus 6.9% respectively
in Tanzania,20 and 40% for female versus 11% for male adolescents
in Peru.3

This differential
indicates that sexual violence is a gender specific event, in which aggression
is itself a form of identifying women's subordination to men.

The rates of sexual
intimate partner violence are even less well known. Such studies concerning
violence perpetrated against men are rare. Considering only heterosexual relationships,
Tjaden & Thoennes27 obtained higher rates of physical and/or
sexual violence by an intimate partner experienced at least once in their lives
among women: 25%, than among men: 8%. In the above mentioned Brazilian study,ª
a rate of 1.4% of sexual violence by an intimate partner was verified among
775 men attending primary health care services within the public health system
of the city of São Paulo, who had had female partners at least once in
their lifetimes.

As to women, since
non-consensual sexual practice is considered in many cultures as a wife's obligation,
it is difficult to circumscribe sexual violence within stable partnerships.
6,9,15 A study designed and coordinated by the World Health Organization
(WHO) 14 for transcultural comparison, conducted between 2000 and
2003 in ten countries, identified that, among reproductive-aged women, the prevalence
of intimate partner violence, occurring at least once in a lifetime, varied
from 6% (cities in Japan, Serbia and Montenegro) to 59% (rural province in Ethiopia).
In the majority of the sites of the study, rates oscillated between 10% and
50%. In this study, Brazil presented a prevalence of 10% in the southeastern
city of São Paulo and of 14% in 15 municipalities of the Northeastern
region, Zona da Mata, Pernambuco. Sexual violence occurred less frequently than
physical or psychological violence, following the general pattern found in the
countries included in this study. 14

On the other hand,
at least among the women, there was a considerable amount of overlapping of
physical and sexual violence (between 30 and 56%). The occurrence of isolated
sexual violence was rare. Although it occurs less frequently, sexual violence,
in association with other forms of physical and psychological violence, has
appeared as a risk factor for several health disorders.4,15 Furthermore,
sexual violence is always considered a severe form of violence.15
Even if it occurred in the past, it produces greater and longer lasting impacts,
such as mental disorders, than other current, but less severe forms of violence
such as slaps and shoves. 10

Special attention
is given to the occurrence of sexually transmitted diseases, particularly HIV/Aids,
as a health condition aggravated by sexual violence. Studies have demonstrated
the relevance of this type of violence in the transmission of HIV/Aids,8,13
emphasizing that it is an important component of the feminization of the epidemic.

Few population
studies have focused simultaneously on men and women when investigating sexual
violence. 26 The objective of this study was to describe the occurrence
and forms of sexual violence perpetrated by intimate partners in urban Brazil,
for men and women.

METHODS

The data analyzed
is part of the survey "Comportamento Sexual e Percepções da
População Brasileira sobre HIV/AIDS", [Sexual Behavior
and perceptions of the Brazilian population concerning HIV/AIDS] conducted
in 2005.b

The sample is composed
of 5,040 individuals, 2,298 men and 2,742 women ranging in age from 16 to 65
years, representing the Brazilian urban population, as described by Bussab.2

Research is based
on representative samples, collected in urban micro-areas, as defined by the
Instituto Brasileiro de Geografia e Estatística [The Brazilian
Institute of Geography and Statistics] (IBGE). According to the sample plan,
stratified in stages, census sectors, private households and individuals over
16 years of age were assorted successively within each micro region. The data
analyzed was adjusted according to primary statistical unit and sample strata,
as described by Bussab.2

As to sexual violence,
the methodology recommended by the World Health Organization and utilized in
a transcultural study sponsored by WHO (Garcia-Moreno14), that included
Brazil was adopted in this study. A cultural adaptation of the instrument and
analysis of the internal consistency of its questions had been undertaken26
at the time of the former study. The questionnaire was based on behaviorally
specific questions that encouraged greater disclosure than requiring respondents
to agree upon certain definitions of violence or to identify themselves as victims
of abuse or rape.

People who replied
positively to at least one of the following questions were considered as having
experienced sexual violence by an intimate partner at least once in their lives:

1) "Were you physically
forced to have sexual intercourse when you did not want to?"; 2) "Did you have
sexual intercourse when you did not want to because you were afraid of what
your partner might do?" and 3) "Were you forced to do something sexual that
you found degrading or humiliating?"

The sociodemographic
variables selected for analysis were: age; self-referred skin color; dichotomized
in Whites and Blacks (Black and Mulatto); educational level; per capita family
income in terms of minimal salaries when research was conducted (R$350,00 -
US$150); macro region of the country; conjugal status; and current working status.

Sexual and reproductive
variables were analyzed: age at first sexual intercourse; existence of the desire
to consummate first sexual intercourse; use of condoms in the first sexual intercourse;
Type of sexual partner in the past five years; number of sexual partners in
the past five years; and occurrence (or diagnosis) of sexually transmitted disease
(STD) at least once during one's life. Furthermore, analysis of the experience
of physical intimate partner violence was conducted.

Variables referring
to life and health experiences with respect to Aids were: do you know someone
personally that has HIV?; what is your self-evaluation concerning your risk
of contracting HIV?; have you ever taken an anti-HIV test?; has your partner
ever wanted to have sexual intercourse and you did not want to? In cases in
which there was a positive response to the last question, the common reaction
of the partner (insists, obliges, seduces, becomes quiet and does not talk about
it, tries to find out what is happening and other reactions).

Descriptive analysis
comprehended the examination of the differences with respect to sexual violence
among men and women according to variables of interest. The F design-based
tests were conducted with a 5% level of significance and the fact that the survey
had a complex sample was taken into consideration. Strata 8.0 was the statistical
program utilized. The complex survey commands (svy) were employed in
correcting the weight, strata and primary statistical unit.

The project of
the survey "Comportamento Sexual e Percepções da População
Brasileira Sobre HIV/Aids" was approved by the Ethics Committee of Faculdade
de Saúde Pública of Universidade de São Paulo.

RESULTS

The sample interviewed
was representative, and the rate of refusal was relatively low.

Sexual partner
violence affected both men and women, having a global prevalence of 8.6% in
the urban Brazilian population. It is significantly predominant among women
(11.8% versus 5.1%; p< 0,001). One in ten women reported having experienced
this type of violence at least once in their lives. This frequency was 2.2 times
greater than the frequency reported by men.

In the Figure,
the differences between men and women with respect to the prevalence of the
various forms of sexual violence are notable. Whereas one third of the women
declared that they had experienced all three forms of violence (forced sexual
intercourse; intercourse due to fear of what the partner might do and submission
to humiliating and degrading sexual practices), one third of the men declared
they had experienced only one of these forms of violence, having been physically
forced to have sexual intercourse. For both men and women, being forced physically
to have sexual intercourse or having intercourse because they were afraid of
their partner's reaction was more frequent than being submitted to practices
considered humiliating or degrading.

By comparing Tables
1 and 2, it becomes clear
that women present greater rates than men for all characteristics studied, except
for male and female homo/bisexuals in which case the rates are similar. The
proportion of women that reported episodes of sexual violence increased with
age, reaching its peak at 25 years of age. As for the men, only "sex because
they were afraid of their partner's reaction" and "humiliating/degrading practices"
presented significant differences according to the individual's age. The Black
population reported a higher frequency of episodes of sexual violence, irrespective
of sex. When violence was disaggregated in its forms, Black men referred experiencing
forced sexual intercourse more frequently than White men. Black women, in turn,
referred having experienced more sex due to fear of their partner's reaction
than White women. There was no difference in terms of skin color with respect
to submission to degrading or humiliating sex practices.

The smaller the
income and the level of education, the larger were the proportion of both women
and men who had experienced sexual violence in general. However this relation
was not observed with respect to degrading/humiliating sex practices among men
and women. Both sex due to fear of their partner's reaction and physically forced
sex were more prevalent among women the lower the income and educational level.
As to the men, only sex due to fear of their partner's reaction was more frequent
among those who had lower educational levels. There was, however, no association
between men's income and the frequency of sexual violence. As to the level of
income, this was not associated with changes in the frequency of any form of
sexual violence. On the other hand, men residing in poorer regions and those
that are less industrialized - North, Northeast and Central West - presented
significantly higher prevalences. There were no significant regional differences
with respect to the prevalence of sexual violence among the women.

As to conjugal
status, men and women that are separated or divorced presented higher rates
of sexual violence, being that women's rates were always higher than men's.
The prevalence of sexual violence among widows was five times greater than among
widowers. Separated, divorced or widowed women report greater frequencies of
sex due to fear of their partner's reaction or humiliating /degrading sexual
practices than other women whereas the rates among men do not vary according
to their conjugal status.

As to occupations
and current working status, greater rates of sexual violence were registered
among women, in decreasing order: maids, unemployed, retired, autonomous worker,
owner of a business, housewives, liberal professionals, employees of the private
sector, civil servants and students. Furthermore for women, their current working
status was significant with respect to all forms of violence. Whereas, among
the men, only sex due to fear of their partner's reaction presented different
frequencies according to working status, being reported more often among the
unemployed, autonomous workers and students.

As Table
3 indicates, significant differences in reports of sexual violence among
men and women can be observed according to sexual and reproductive status. Sexual
violence occurred more frequently among women who declared they had had sexual
intercourse before they were 15 years old, who were obliged or who did not want
to have their first experience in sexual intercourse, who did not use condoms
that time, or who had some kind of STD at any time in their lives. Sexual violence
was also greater among women with four or more partners in the five years previous
to the interview. Among the men, there was no variation in the prevalence of
sexual violence according to the age at which they had their first experience
in sexual intercourse, the use of condoms at that time or the number of sexual
partners in the five years previous to the interview. On the other hand, like
the women, prevalence of sexual violence was greater among the men who did not
want to or were forced to have their first experience in sexual intercourse
and among those who had some kind of STD at any time in their lives. Men with
homo or bisexual partners in the five years prior to the interview presented
the highest prevalence of sexual violence. It was five times higher than the
rates of sexual violence among men with heterosexual partners in the five years
prior to the interview. This difference was not observed among the women.

Differences with
respect to the occurrence of sexual violence according to some life and health
experiences are presented on Table 4.

As indicated in
this table, greater rates of sexual violence were reported by both men and women
who knew someone personally who had HIV; who evaluated themselves as being at
risk for contracting HIV; whose sexual partner wanted to have sexual intercourse,
when he/she didn't; whose partner usually insists or seduces (when the individual
interviewed was a man) and usually obliges or insists (when the individual interviewed
was a woman) in having sexual intercourse; and whose partner is physically violent.
However, there were no significant differences in the rates of sexual violence
among men and women who had submitted themselves to anti-HIV tests at least
once in their lives.

DISCUSSION

This is the first
nationwide population based study undertaken with both men and women that documents
the occurrence of sexual violence by an intimate partner in Brazil. It is also
the first study of this nature to consider both heterosexual and homo and bisexual
individuals. The results of this study indicate that the entire Brazilian population
experiences episodes of sexual violence although this occurs in different rates,
depending on a series of factors, and in smaller magnitudes than physical and
psychological violence.26,ª However, it should
be emphasized that the meaning of violence for the subjects involved, whether
these are victims or aggressors, does not ensue mechanically from its magnitude.25

The magnitudes
reported by both men and women are always high, coinciding with findings from
the international literature.14,15,18 However, among homo and bisexual
individuals, the prevalence of sexual violence is greater, among both men and
women. On the other hand, among heterosexuals, women present a rate twice as
high as men. Yet, for men, the prevalence of sexual violence among homosexuals
was approximately four times greater than among heterosexuals. Among women,
the difference between homo/bisexuals and heterosexuals was not significant.

According to the
theoretical perspective of gender relations, 14,15, 21, 25 violence,
above all sexual violence, is explained as a kind of behavior, principally masculine.
This masculine behavior is explained as an attempt to reinstate the individuals
power or to avoid the loss of power in situations in which male and female attributions
are changing and result in conflicts with respect to traditional hierarchical
relationships. In this sense, the results of this study reiterate this theoretical
perspective, making it possible to pose the following hypothesis: among heterosexual
couples, the woman is the major victim of violence, whereas among both male
and female homosexual partners, there seems to be a crisis in the relationships
with respect to traditional identities that also generates violence.

The general results
of this study coincide with those of the literature in several aspects: the
greater rate of sexual violence perpetrated against women than among men as
well as the increase in prevalence among women as they grow older. An increase
in the prevalence of sexual violence is also associated with lower educational
level and lower income. There is also a greater prevalence of sexual violence
among both men and women who are separated or divorced.

However, the distinct
magnitudes in the rates found among men and women and their profile with respect
to differentials such as educational level and income also lead to a discussion
of the role of gender in behavior classified as sexual violence in different
social strata. In this sense, the existence of diverse gradients was observed
between men and women, with respect to the prevalence of sexual violence according
to both educational level and income.

An unprecedented
finding within Brazil was the larger rate of sexual violence among Blacks, both
men and women. These findings are reiterated with respect to forced sex for
fear among Black women and sex forced physically among Black men. Despite the
higher rates of sexual violence among Blacks when compared to Whites, White
women still attain higher rates than those of Black men. In this case as well
gender relations permeate ethnic issues.

On the contrary
of the possible common sense assumption with regard to the greater vulnerability
of housewives, or of women who remain in the domestic sphere, the results of
this study reveal a greater complexity with respect to the association between
sexual violence and permanence within the domestic sphere, for some working
segments presented elevated rates of sexual violence. Once again, the issue
of the crises in traditional gender identities comes forth, being this traditional
identity represented by the woman whose occupational sphere is restricted to
the home. This argument is reinforced by the fact that among the men, different
current working statuses did not significantly affect the rates of sexual violence.
Once again, gender relations interact differentially with class relations for
men and women.

In this same sense,
for men, sexual partnership with more than one partner in the five years prior
to the interview or the fact that they reported that their first experience
with sexual intercourse occurred before they were 15 years old or that condoms
were not utilized in this first experience had no significant impact on rates
of sexual violence. On the other hand, these factors result in different rates
of sexual violence among women, implying in gender issues and women's particular
vulnerability to STDs.

Another finding
that is coherent with the literature is the higher prevalences of sexual violence
among men and women who reported that they were obliged to have their first
experience with sexual intercourse, and in the case of the women, those who
stated they did not desire that first experience although it was consummated.

As to the relation
between sexual violence and the greater vulnerability to sexually transmitted
diseases and HIV/AIDS, the results of this study also reinforce data from the
international literature,9,13,18 particularly in regard to the association
with the perception of greater risk for HIV or the previous occurrence of STDs.
Yet, having anti-HIV tests at least once in their lives did not present differences
between men and women with respect to reported sexual violence. This contrasts
with the self perception of being at risk for contracting HIV, suggesting that
being tested is not subordinated to a perception of risk and, perhaps, is related
to the fact that this test is systematically offered, for example, as part of
routine pre-natal care and when individuals donate blood. From the perspective
of life and health experiences related to the AIDS epidemic, this study confirms
that sexual violence is an important factor to be considered in research and
in the organization of services for the prevention of HIV and care for those
that test positively.

One of the limitations
of this study is a possible information bias. Studies on violence undertaken
with women usually point out that it is underestimated due to difficulties with
respect to disclosure.11,15,16 Studies involving men are less frequent,
particularly those in which they figure as victims of sexual violence. When
the victim is an adult man, disclosure seems to be even more jeopardized. This
is indicated by the fact that among denunciations to the police, less than 5%
of the cases of sexual violence notified are perpetrated against men.17,23
Another study that reinforces the occurrence of male sub notification was conducted
in São Paulo and dealt with sexual crimes.5 This study certified
that 8.8% of the cases were perpetrated against men, the majority of whom had
been abused during childhood or adolescence. A third study in the same vein,
but undertaken with a qualitative approach, reports the case of a man who, after
having sexual violence perpetrated against him was discouraged from seeking
assistance in a municipal hospital in the city of São Paulo that attends
victims of sexual violence.24

Gender issues are
at the root of these problems related to disclosure. For men, it is a question
of avoiding a proximity to female identity, whose socio-cultural devaluation
explains the surtax of women. For women, shame and self-blame with regard to
the episodes of violence perpetrated against them is what makes them refuse
disclosure.15,16 This aspect is illustrated by the finding that 40%
of the face to face interviews had less disclosure than anonymous information
solicited from the same women interviewed concerning sexual violence perpetrated
against them when they were under 15 years of age, in a Brazilian populational
study,c with women from 15
to 49 years of age, that was part of a WHO multi-country study.14
Another Brazilian study with 1,193 adolescents, both men (45.6% of the sample)
and women, studying in the 8th grade in Porto Alegre, the capital
of the Southern State of Rio Grande do Sul, indicated that if, on one hand,
2.3% of them disclosed that they had been victims of sexual violence, on the
other, 4.5% had witnessed some form of sexual violence and 27.9% reported that
they knew someone who had been a victim of sexual violence.22

However, considering
the magnitudes found in this study and the effects of sexual violence, particularly
when perpetrated by an intimate partner, in various dimensions of human health,
new investigations are necessary in order to better understand its determinants
and impacts. Such research can also contribute to the discussion of effective
forms of assistance as well as the creation of policies for the eradication
of sexual violence. The results of the present study shall be the object of
future analyses by means of multivariate models.